In an exclusive interview with ConvergenceRI, Sen. Sheldon Whitehouse shares his views on bipartisanship, hospital mergers, the art of political debate, and the future of health care.

The questions that need to asked

How can patients participate in the decision-making about what they see as their needs within the health care ecosystem? How does the development of Neighborhood Health Stations and community health centers become part of the calculation around future health care delivery? What are limits of technology in solving problems in the delivery of health care services, as demonstrated by the continued disaster that is the Unified Health Infrastructure Project, or UHIP? Why doesn’t the work around health equity zones resonate with Sen. Whitehouse? What is the messaging that Democrats should adopt around the next phase of health care reform?

Under the radar screen

Lost in the ongoing debate around whether or not there is a Rhode Island health care system is the absence of any statewide planning document to define what such a health care system should look like. The reality is that, as Dr. Michael Fine often says, we have a market that is expert in wealth extraction, not a health care delivery system.
Further, the consolidation of hospital systems is being driven by the economic imperatives of the changing business model for reimbursement, moving toward value over volume, toward a continuum of care and population health over fee for service, changes that have been championed by Medicare and Medicaid as well as Sen. Whitehouse. The consequences, whether intended or not, is that hospital systems need to consolidate to survive, to serve a “large enough” population, given the slimmer operating margins. Mergers and consolidations, particularly in a small state such as Rhode Island, are inevitable.
Comparisons to what happened with the banking industry in Rhode Island are only analogous up to a point: what really happened with the banking industry was a changeover to online banking and risk-leveraged investments in hedge funds by corporate banking entities. There are numerous examples of Rhode Island entrepreneurs who developed new approaches to banking and to processing transactions.
Finally, there is a legitimate debate that needs to happen about how future investments are made: in support of the current system, or in the development of a community-based system that reflects the needs of the patients rather than the providers. The question is: who gets to participate in that debate and decision-making?

PROVIDENCE – The sit down interview on Friday, July 28, with Sen. Sheldon Whitehouse at his local office had been scheduled for more than a week. But no one could have predicted the tumultuous beginning to the day, with Sen. John McCain casting the decisive vote with a dramatic, thumbs down gesture to kill the proposed “skinny” repeal of Obamacare in the U.S. Senate at around 1:30 a.m.

Flying back to Rhode Island, Whitehouse held a media briefing at T.F. Green Airport with his colleague, Sen. Jack Reed, and then it was back to his Providence office on Westminster Street for a series of back-to-back meetings.

CommerceRI Secretary Stefan Pryor was leaving just as ConvergenceRI arrived. At first, ConvergenceRI didn’t recognize Pryor, who has shaved off his beard.

In the interview, Whitehouse began the conversation by acknowledging that the “bullet” that was the planned repeal and replace of Obamacare with Trumpcare had “missed.”

Whitehouse spoke with an assured, confident voice: he stressed that bipartisanship in Washington is alive and well and prospering.

“Not only is there hope for bipartisanship,” Whitehouse explained, “I think one of the failings of the press is to under-report bipartisanship because the fight is so much fun to report.”

Anthony Scaramucci [the new White House communications director], Whitehouse continued, “says horrible and vulgar things about other people in the White House, and everybody in the country hears about it, because we’re fascinating by the conflict. Something big could be happening on a quiet, bipartisan basis in the Senate, and it’s just not news.”

As a result, Whitehouse said, “the American public gets a distorted view of how partisan the actual environment is.”

Whitehouse cited the example of Oklahoma Sen. James Inhofe, whom Whitehouse described as “my worst nemesis on climate change issues; I think his beliefs on climate change are a disgrace.” But Inhofe signed on to become an initial co-sponsor of Whitehouse’s Marine Plastics Debris Bill, and Inhofe also joined the bipartisan Oceans Caucus that Whitehouse established.

Whitehouse also expressed worries about a potential tipping point being reached in the ongoing consolidation of hospitals in Rhode Island, in particular, the proposed merger of Care New England with Partners Healthcare, because it may cause Lifespan to find a partner. Comparing the current situation what happened with the local banking industry in the 1990s, Whitehouse said he feared the same of kind of “great sucking sound” of legal and accounting support businesses leaving the state when the banks consolidated and moved their headquarters would be replicated with hospitals.

Finally, Whitehouse declared the proposed Trump budget, particularly where it concerned cutting investments in scientific research, had no traction. “The bad news is that the Trump budget is a nightmare for research,” he said. The good news is that because it is such a nightmare, it is getting virtually no traction.”

Here is the ConvergenceRI interview with Sen. Sheldon Whitehouse, at a time of great turbulence and upheaval in the nation and in Rhode Island.

ConvergenceRI: As you said, the bullet didn’t hit us, when it came to the proposed plans to repeal and replace Obamacare. Where do we go from here?WHITEHOUSE: To committee, I hope. I think that both Sen. Lamar Alexander, chair of the Health, [Education, Labor and Pensions] Committee, and Sen. Orrin Hatch, chair of the Finance Committee, are experienced and able legislators with a history of bipartisan achievements, so that puts us off to a strong start.

There’s enormous, pent-up interest. This has sort of a blockade for anything else while we’ve been having this row. How important are such activities to the process going forward?

ConvergenceRI: Citizen activism clearly seemed to have played a big part of what happened in how things turned out in the Senate. How important will those activities be to the process going forward?WHITEHOUSE: You could actually watch citizen advocacy having its effect on the bill as it morphed through this process. There is a reason why [Republicans] first tried to offset their Medicaid cuts with an opioid spending bump, and then afterwards, eliminated the Medicaid cuts entirely. I think the Republicans learned a lot about Medicaid through this process.

ConvergenceRI: Moving forward, is there a need to be able to translate the Democratic messaging on health care into simpler messages? If you had a simple message to deliver, what would it be? How can the dialogue be reframed?WHITEHOUSE: With health care, we have to look at the problem areas that have not gotten enough attention, and the win-win prospects, rather than just going to where the fight last was, and restarting that [argument].

ConvergenceRI: So, what’s the messaging? Not to put you on the spot.WHITEHOUSE: If we do our jobs right, in a regular ordered process for health care coverage in conference, I think the message can be very simple: “Here is a bill that will really help you.”

ConvergenceRI: Could Rhode Island, because of its size, and also because of its innovative approach to health care reform, offer some lessons on how to move forward with health care delivery? What do you see as the kinds of best practices that Rhode Island could share as a way to move the debate forward?WHITEHOUSE: We certainly are a leader on health information exchange. We can be very valuable in explaining why that helps people.

We are the leader with the All Payer Claims Database [as a way to] aggregate health information, which has huge research opportunities.

If you can bring big data to work on Wall Street, and bring big data to work on science, you bring big data to work on health care.

We have two very big and well-regarded primary care provider groups – Coastal Medical and the Rhode Island Primary Care Physicians, which are proving that you can lower costs while improving care.

And, I don’t mean just bend the cost curve down; I mean bend it so that it is actually going down.

I think these are three of the signal Rhode Island achievements.

We have two other pending initiatives; one is to create a new paradigm for end-of-life care, where the system does a good job of determining and honoring the patients’ wishes rather than grinding them through procedure after procedure.

And the second is: how we do the next Medicaid waiver reform program, which we are just at the beginning edges of, [so that it] has the capacity to pull a lot of these pieces together in a new way.

ConvergenceRI: Can you explain further what you mean?WHITEHOUSE: It’s nice to have a really robust electronic health record that is available throughout wherever you get your health care on the health information exchange. But if you haven’t got doctors who have the incentive to use that information to make you healthier, then it doesn’t really stand on its own. If you come to a point in your life where you are not capable of making decisions, or aren’t capable of communicating your decisions, and nobody has bothered to figure out in advance what you want, then even your doctors can’t help with that.

So, the piece of that is fitting it together into a virtuous circle.

ConvergenceRI: One of the things that you didn’t mention is the ongoing effort to create health equity zones in 10 Rhode Island communities, as a way to invest in community-based needs. Depending on the way you calculate it, some 85 percent to 95 percent of health outcomes do not get addressed when you visit a doctor’s or a nurse’s office. The health equity zones are an attempt to address the issues of social and economic disparity, including housing and food insecurity.WHITEHOUSE: I think it may be a piece of [the puzzle], but I think you have to come at [the problems with health care] of making the system work better for people, rather than just adding more expense and activity to a system that isn’t working better for people.

So, as a perfect example to your point, Peter Marino, [the president and CEO] at Neighborhood [Health Plan of Rhode Island], talked about taking the trouble, I think for the first time, to figure out what was behind the high expenditures for some of their high expenditure patients.

They determined that one of their emergency room patients was spending an awful lot of time there, so they sent a social worker to go and talk to the person, to find out why he was spending so much time in the emergency room.

And, it turned out that the cost-effective solution was to buy him an air conditioner.

He was hot, he was lonely, and once he had an air conditioner and he could watch TV comfortably at home, his emergency room visits went dramatically down. And, it saved [Neighborhood Health Plan] tens of thousands of dollars against the cost of [buying] an air conditioner at Walmart.

So, that to me is the sum of the story: if doctors are rewarded for keeping you healthy, they can find ways to drive costs out of the system to make everyone happier.

This isn’t taking care away from sick people; it’s making sure that care gets to people where it needs to be, when it needs to be.

ConvergenceRI: How does that kind of thinking play out with the opioid crisis? There were 336 Rhode Islanders who died last year as a result of ODs, with over half involving fentanyl. There is a lot of conversation around adopting harm reduction strategies, such as safe injection sites, and providing testing strips for fentanyl along with Narcan, as has been successfully in Vancouver, British Columbia.

Also, the statistics around what some sociologists call the diseases of despair are pretty remarkable: for the age group of 25-34 for white adults in Rhode Island, some 60 percent of all deaths were from drugs, alcohol or suicide between 2010 and 2014, according to CDC statistics. Those deaths have been linked to the economic devastation of the middle class.WHITEHOUSE: When you are dealing with a topic as broad as economic devastation of the middle class, it is hard to get your arms around any kind of specific solutions. But if you draw the problem down to what to do to try to have more successful approaches to dealing with people who are addicted, the two things that I see that I like the most are:

• Recovery coaches being on scene in the emergency rooms, so that when somebody comes out of an overdose, and the Narcan kicks in, there is somebody who has the experience of addiction and knows what the network of support looks like, and [who] can speak to them as a peer, to help them seize that opportunity to make the decisions to turn on the path toward recovery.

• The second, in a related program, now [in operation] in Providence, Warwick and West Warwick, is where you have addiction recovery professional [who is] embedded in the police department, and doing ride-alongs in the cruisers, and being on call to handle crisis situations.

I was just talking with a woman who was doing [this work] in West Warwick last week, Heather, and her enthusiasm for what she was doing, her excitement about what she got to do when she got up in the morning, and the enthusiasm of the police officer who was her liaison for what they were achieving together, and the enthusiasm of the police chief for how well this was working for them, was really something wonderful to behold.

ConvergenceRI: How do you see the musical chairs that is involved with the current consolidation of hospital systems in Rhode Island? In particular, with the plans by Care New England to merge with Partners Healthcare in Boston? Is that something that we need to let play out? Should the state become involved?WHITEHOUSE: Here is the worry that I see. Go back 25 years, and we had major banks here in Rhode Island, that were headquartered here in Rhode island, whose CEOs were important community leaders in Rhode Island, and which obtained their accounting legal and other professional services right here in Rhode Island. It was a really strong ecosystem.

Then came consolidation, and our banks’ headquarters moved out of state, and in one case, out of the country.

And, with that move, [there] went the business for the law firms; if your headquarters are in Boston, you don’t need to work with a Providence law firm, [the same with] accountants. There was a real blow to the Rhode Island economy.

The reason I talk about that is the same thing could happen in the hospital industry. We have hospitals now owned by [companies] in Connecticut and California and soon to be Boston, assuming the Care New England deal goes through.

What happens when Care New England and all the other hospitals are owned by large corporations with out of state headquarters, and now Lifespan decides it’s the small dog in the fight, and it’s used to being the big dog, so now it needs to find a partner out of state.

And with that goes all the [ancillary] business, just like with the banks.

Rhode Island now has [the capacity] to chart its own health care future, by getting doctors and hospitals and nurses and insurers in a room together and deciding something like: we’re going to have the best health information exchange in the country. Which we did; we accomplished that.

The laggard in all of this was UnitedHealthcare. There is nothing wrong with United; they are very, very nice people, but the fact that their headquarters is in Minneapolis means that they are not able to move [quickly] in Rhode Island, in ways that allow us to have a Rhode Island health care destiny.

The big concern for me is that the Care New England merger is the tipping point that causes Lifespan to have one, too. And then, as with the banks, the great sucking sound of everything leaving the state gets replicated with hospitals.

ConvergenceRI: Let me push back a bit. Hasn’t the horse already left the barn? Prime Healthcare owns Landmark and soon Memorial; CharterCARE is owned by Prospect Medical in California; Westerly is now owned by Yale-New Haven…WHITEHOUSE: [interrupting] …That’s my point. It’s underway, yes. But there is still a tipping point that we haven’t reached yet, because Care New England and Lifespan are still Rhode Island-based.

And, if they both go, we lose our ability to call the CEOs all together and work on solving problems.

ConvergenceRI: The innovation economy in Rhode Island is built upon investments in research – basic, applied and translational research. How much does the proposed Trump budget and its proposed cuts in scientific research threaten to undermine the emerging innovation ecosystem here in Rhode Island?WHITEHOUSE: The bad news is that the Trump budget is a nightmare for research. The good news is that it is such a nightmare that it’s getting virtually no traction in Congress, even from Republicans.

It is astonishing to me to see how little traction the Trump budget proposals have had. The last funding measure that we passed earlier this year, ending in September, was negotiated between Republicans and Democrats in the Senate and in the House. The White House, for all intents and purposes, was not even in the room.

The moral of the story is that when the budget is too terrible, nobody pays attention to you any longer; they don’t think you’re serious.

ConvergenceRI: How do we restore a sense of civility in the way that people talk with each other?WHITEHOUSE: It’s a tough question, because civility is a virtue, and it has been a virtue for a very long time. At the same time, misbehavior needs to be called out.

Robust debate is something upon which the American democracy was founded. When you read some of the things that were written by the founding fathers about each other, and you go through the history of some of the political wars that we’ve had, [you recognize] that we are not a puffball democracy. So, to me, the key is to be able to distinguish between when you really need to have a fight, and when you don’t. It’s one of the skills that you learn in the Senate.